Former Employers (List below last four employers, starting with last one first)

Date/Month and Year

Name & Address of Employer

Salary

Position

Reason for Leaving

From:To:

From:To:

From:To:

From:To:

References (Give below the names of three persons not related to you,whom you have known at least one year.)

Name

Address

Business

Years Known

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorized investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, inless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohebited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."